What are the steps for open inguinal hernioplasty for a right indirect inguinal hernia?

Steps of Open Inguinal Hernioplasty for Right Indirect Inguinal Hernia

The Lichtenstein tension-free mesh repair is the gold standard approach for open inguinal hernia repair, offering lower recurrence rates, easier learning curve, and wide applicability compared to other techniques. 1

Preoperative Preparation

• Confirm diagnosis through physical examination and imaging if needed
• Ultrasonography is recommended as first-line imaging when diagnosis is uncertain (sensitivity 92.7%, specificity 81.5%) 2
• Ensure patient is suitable for surgery and anesthesia
• Consider local anesthesia when possible, as it offers advantages over general anesthesia 3

Surgical Steps

1. Incision and Exposure

• Make a 5-6 cm oblique incision approximately 2 cm above the inguinal ligament, starting from the pubic tubercle and extending laterally
• Divide subcutaneous tissue and Scarpa's fascia to expose the external oblique aponeurosis
• Identify and protect the ilioinguinal nerve

2. Opening the Inguinal Canal

• Incise the external oblique aponeurosis along the direction of its fibers, starting from the external ring and extending laterally
• Develop upper and lower flaps of the external oblique aponeurosis
• Identify and protect the ilioinguinal and iliohypogastric nerves
• Mobilize the spermatic cord with its coverings using blunt dissection

3. Hernia Sac Identification and Management

• Identify the indirect hernia sac anteromedial to the cord structures
• Carefully separate the sac from the cord structures
• Open the sac and inspect contents, reducing any contents back into the peritoneal cavity
• High ligation of the sac at the internal ring level
• Excise redundant sac and close the peritoneum with absorbable suture

4. Mesh Placement (Lichtenstein Technique)

• Prepare a polypropylene mesh (approximately 8 × 12 cm)
• Shape the mesh to fit the inguinal floor with a slit for the spermatic cord
• Position the mesh over the posterior wall of the inguinal canal, extending 2-3 cm medial to the pubic tubercle and 3-4 cm above the Hesselbach's triangle
• Secure the mesh with non-absorbable sutures:
  • Continuous suture along the inferior edge to the inguinal ligament
  • Interrupted sutures to the conjoint tendon superiorly
  • Create a new internal ring by suturing the mesh tails around the spermatic cord

5. Closure

• Close the external oblique aponeurosis over the cord with absorbable sutures
• Close Scarpa's fascia and subcutaneous tissue with absorbable sutures
• Close skin with subcuticular sutures or staples

Postoperative Management

• Multimodal pain management including acetaminophen as first-line treatment, NSAIDs when not contraindicated, and minimizing opioid use 2
• Early ambulation and return to normal activities as tolerated
• Monitor for potential complications: seroma, hematoma, wound infection, chronic pain

Important Considerations

• While laparoscopic approaches (TEP, TAPP) are viable alternatives, open mesh repair has a lower recurrence rate when performed by less experienced surgeons 1
• The open approach is particularly valuable for recurrent hernias after a posterior approach and for patients with pubic inguinal pain syndrome 3
• Local anesthesia can be used for open repair, which is advantageous but requires training and excellent knowledge of anatomy 3

Potential Pitfalls to Avoid

• Injury to the ilioinguinal, iliohypogastric, or genital branch of the genitofemoral nerve
• Inadequate mesh size or improper fixation leading to recurrence
• Failure to distinguish between direct and indirect hernias can lead to incorrect treatment 2
• Overlooking potential systemic causes of hernia such as heart failure or portal hypertension 2

The open Lichtenstein repair remains widely applicable due to its effectiveness, lower learning curve, and ability to be performed under local anesthesia, making it accessible in various healthcare settings worldwide.